Sherwood Oaks Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Thousand Oaks, California.
- Location
- 250 Fairview Road, Thousand Oaks, California 91361
- CMS Provider Number
- 555794
- Inspections on file
- 63
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Sherwood Oaks Post Acute during CMS and state inspections, most recent first.
A resident's representative was not informed of a rescheduled cardiovascular appointment, despite facility policy requiring notification of pending appointments and transportation arrangements. Documentation showed the appointment date was changed, but there was no record of notification to the responsible party, and staff confirmed this omission.
A shower room was found to be unsanitary and in disrepair, with issues such as a broken doorframe, damaged tiles, an improvised call light cord made from plastic bags, and improper storage of personal care items and sharps. These conditions were confirmed by the Maintenance Director and did not meet the facility's policy for a safe and clean environment.
Staff did not follow facility policy for labeling and storing perishable foods brought in by family or visitors. An Infection Preventionist found a plastic bag with a partially browned head of lettuce and two half-eaten sandwiches in the resident refrigerator, all unlabeled and undated. The Infection Preventionist confirmed these items should have been labeled with the resident's name and date, and could not determine how long the items had been stored.
The facility did not display the required State Survey Agency contact information and a statement about residents' rights to file complaints. A resident with moderate cognitive impairment was unaware of their rights due to this oversight. Interviews with staff, including a CNA and the DON, confirmed the absence of postings, and the Administrator acknowledged the failure in the facility's review process.
A facility failed to report a resident-to-resident abuse allegation within the required timeframe. An incident occurred where a resident reported being bumped by another resident, leading to police involvement. Despite the facility's policy requiring immediate reporting, the State Agency was not notified until several days later. Interviews revealed a lack of communication and understanding of the incident's severity among staff.
A resident was admitted with a diagnosis of psychosis and depression, but the facility failed to conduct a Level II PASRR as required. The resident's Level I PASRR did not identify any serious mental illness, and the diagnosis was missed during the admission process, particularly because it occurred over a weekend. Facility staff acknowledged the oversight in reviewing the resident's diagnosis and medications.
A resident with Alzheimer's Disease lost their custom-built hearing aids, and the facility failed to replace them in a timely manner. Instead, generic hearing aids were provided, which did not fit properly and were frequently lost. Observations confirmed the resident was without hearing aids and unable to communicate effectively. The request for replacement was still pending approval by management.
A resident in an LTC facility gave $740 to a CNA after the CNA expressed financial difficulties. The facility's policies prohibit such transactions, yet the CNA accepted the money, which was later returned in the presence of staff. This incident highlights a failure to protect the resident from financial exploitation.
A facility failed to implement a comprehensive care plan and follow physician orders for a resident with depression. The resident's care plan required administering Trazadone as ordered, but the MAR showed missing entries for monitoring depression and side effects, and the resident missed a dose. The DON and MRD acknowledged these issues but lacked documentation to confirm compliance with physician orders.
A facility failed to provide a resident's medical records in a timely manner to the resident's representative, despite a verbal and written request. The facility required a specific authorization form to be signed before releasing records, which was not aligned with their policy allowing access within 48 hours of a request. This resulted in a violation of the resident's rights.
A facility failed to implement a care plan intervention for a resident with a urinary tract infection, which required monitoring of intake and output. The Director of Nursing and Medical Records Director could not provide documentation that this intervention was carried out, despite the facility's policy requiring comprehensive, person-centered care plans with measurable objectives.
A facility failed to follow physician orders for catheter care for a resident, risking negative outcomes like urinary tract infections. The resident's Treatment Administration Record (TAR) showed missing entries for monitoring urine character and catheter placement over several months. This was confirmed by the DON and MRD during a review.
A resident did not receive a scheduled dose of Metoprolol due to a failure to follow physician orders and facility procedures. The resident's vital signs were within the parameters for administration, but the medication was withheld. The care plan required adherence to medication parameters, which was not followed, and the facility's documentation policy was not adhered to.
A facility failed to document the implementation of a fall prevention intervention for a resident with a history of falls and recent injuries. Despite having a care plan that required regular checks and assistance with toileting, there was no documentation to confirm these actions were carried out after the resident returned from the hospital. This oversight was identified during a review of the resident's medical record by the DON and Medical Records Director.
A facility failed to ensure timely monitoring and skin evaluation for a resident admitted after knee surgery. Despite orders to check for skin integrity, no assessments were documented until a deep tissue injury was found on the resident's heel two days after cast removal. The wound was later classified as stage IV.
A resident with a high risk of falling experienced an unwitnessed fall and subsequent hip fracture, but the facility failed to revise the care plan with new interventions. Despite an IDT meeting, the care plan remained unchanged until weeks later, contrary to the facility's policy.
Failure to Notify Resident Representative of Rescheduled Medical Appointment
Penalty
Summary
The facility failed to notify the resident representative (RR) of a rescheduled medical appointment for one of two sampled residents, as required by their own policy. The RR reported that an appointment with a cardiovascular physician was changed by the provider, but the facility did not inform the RR, resulting in the RR being unable to attend the appointment. Review of the resident's progress notes showed documentation of the original and updated appointment dates, but there was no indication that the RR was notified of the change. The facility's policy on transporting residents to appointments specifies that the resident and/or responsible party will be notified of pending appointments and necessary transportation arrangements. During an interview, the Social Services Director confirmed that the RR should have been notified and acknowledged that the progress notes did not reflect such notification.
Plan Of Correction
A. What corrective action(s) will be accomplished for the patient(s) identified to have been affected by the deficient practice. It was documented in Resident 1's medical record that on 09/25/25, D.O.N. reviewed with resident's son (Michael) the findings and recommendations of the 9/24/25 vascular appointment. He did not have any issues. Resident 1 was discharged to an Independent Living Facility on 11/7/25 in stable condition and with no negative outcome. B. How other patients having the potential to be affected by the same deficient practice will be identified, and what corrective action will be taken. On 11/6/25, D.O.N. reviewed all scheduled appointments for the month of November. There are no issues on resident and/or responsible party notification of the appointment. C. What immediate measures and systemic changes will be put into place to ensure that the deficient practice does not recur. On 11/5/25 and 11/6/25, DON conducted an in-service to the licensed nurses and department managers to review the policy and procedure on "Resident's Appointments". Social Service staff will inform the resident, responsible party (if applicable), and nurses for any change in the appointment schedule. Social Service staff and Nursing will utilize the Scheduled Appointment Information form as a source of communication. D. How the facility plans to monitor its performance to ensure corrections are achieved and sustained. The plan of correction must be implemented, corrective action evaluated for its effectiveness, and it must be integrated into the quality assurance system. On 11/6/25, a QAPI Plan "Resident's Appointment Notification" was initiated by the IDT. Medical records will audit MD orders daily 5x/week to ensure that the resident and/or responsible party are notified of the appointments and documented in the record. D.O.N. and Administrator will be given a copy of the audit to ensure compliance. Findings of the audit will be discussed during the QAPI Committee meeting monthly x3 then quarterly and follow their recommendation for continued compliance. E. Dates when corrective action will be completed: November 11, 2025
Unsanitary and Unsafe Shower Room Conditions
Penalty
Summary
A shower room located in hallway four was found to be unsanitary and in disrepair during an inspection conducted with the Maintenance Director. Observations included a shower doorframe in a state of disrepair, broken wall tiles, and a call light cord that was broken and had been replaced with plastic bags instead of a proper replacement. Additionally, a bottle of lotion was stored on top of a dirty sharps container, and a used razor was found in a plastic cup placed atop a box of clean gloves. The Maintenance Director confirmed these findings during the inspection. Review of the facility's policy indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not maintained in this instance.
Failure to Adhere to Food Storage and Labeling Policy for Resident Food Brought by Visitors
Penalty
Summary
Facility staff failed to follow the established policy and procedure regarding the storage and labeling of foods brought in by family and visitors for residents. During an inspection of the resident refrigerator, an Infection Preventionist observed an unlabeled and undated plastic bag containing a partially browned head of lettuce and two half-eaten sandwiches in plastic containers, also unlabeled and undated. The Infection Preventionist confirmed that these items should have been labeled with the resident's name and date, as per facility policy. When questioned, the Infection Preventionist was unable to determine how long the items had been in the refrigerator, though stated that the facility practice was to clean out the refrigerator weekly. Review of the facility's policy indicated that perishable foods must be stored in resealable containers with tightly fitting lids, labeled with the resident's name, item, and use-by date, and that staff are responsible for discarding foods showing signs of potential foodborne danger.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to comply with federal posting requirements by not displaying the State Survey Agency contact information and a statement regarding residents' rights to file a complaint. This deficiency was identified during an observation of the facility's bulletin board, which lacked the necessary postings. The facility's policy, titled 'Federal Posting Policy,' mandates the display of such information in publicly accessible areas to inform residents, employees, and visitors of their rights under federal law. However, the absence of this information was confirmed through interviews with a resident, a CNA, the DON, and the Administrator, all of whom acknowledged the lack of required postings. A resident with moderate cognitive impairment, as indicated by a BIMS score of 12, was unaware of their right to file a complaint with the state agency due to the absence of the necessary information. The CNA and the DON also confirmed the lack of awareness and absence of postings. The Administrator admitted that the facility's monthly review process failed to ensure the required information was posted, acknowledging the oversight and expressing an expectation that all necessary data should be displayed.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident-to-resident abuse allegation to the State Agency within the required two-hour timeframe. On January 27, 2025, an incident occurred where Resident #39 reported that Resident #7 bumped into their wheelchair and knee. The police were called by Resident #39, but the facility did not notify the State Agency of the incident until February 5, 2025. The facility's policy mandates that any suspected abuse must be reported immediately or within 24 hours, but this protocol was not followed. Resident #39, who was admitted to the facility in 2019, has a medical history that includes depression and a traumatic brain injury. The resident reported feeling unsafe after the incident, although they were not physically hurt. Resident #7, admitted in 2021, has a history of chronic pain syndrome and bipolar disorder. Both residents have intact cognition as indicated by their BIMS scores. The facility's care plans for both residents were updated on February 4, 2025, to address the risk of emotional distress due to the disagreement. Interviews with staff revealed a lack of communication and understanding of the incident's severity. The Director of Nursing and Operations Manager were informed of a verbal disagreement but not of any physical contact. The Administrator was aware of the police presence but did not report the incident to the State Agency, relying on the police's assessment that no crime occurred. This oversight led to a delay in reporting the abuse allegation, violating the facility's policy and state regulations.
Failure to Conduct Level II PASRR for Resident with Psychosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASRR) despite the resident being admitted with a diagnosis of psychosis and depression. The facility's policy requires verification of a Level I PASRR screen for potential admissions to determine if a Level II screening is necessary. However, the resident's Level I PASRR screening did not identify any serious mental illness, and the resident was admitted without a Level II screening. The resident's medical history included unspecified psychosis and depression, and the resident was on antipsychotic and antidepressant medications. Interviews with facility staff revealed that the PASRR process was not followed correctly. The Admission Director and MDS Coordinator both acknowledged that the diagnosis of psychosis was missed during the admission process, particularly because the admission occurred over a weekend. The Director of Nursing and the Administrator confirmed that the admissions staff are responsible for reviewing new admissions to determine if a Level II screening is required, but the diagnosis of psychosis was overlooked in this case.
Failure to Replace Lost Custom-Built Hearing Aids
Penalty
Summary
The facility failed to uphold the resident's right to be treated with respect and dignity by not replacing custom-built hearing aids for a resident in a timely manner. The resident, who was admitted with Alzheimer's Disease, had custom-built hearing aids documented in their inventory of personal effects upon admission. However, these hearing aids were lost in July of the previous year, and the facility provided generic hearing aids that were ill-fitting and frequently fell off, leading to further loss. Interviews and observations revealed that the resident was without hearing aids, unable to hear or understand questions, and the request for replacement hearing aids was still pending approval by upper management. The operations manager acknowledged awareness of the situation and agreed that the resident's quality of life could be affected by the inability to hear, which impedes effective communication between the resident and staff.
Misappropriation of Resident's Money by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically involving a financial transaction with a Certified Nursing Assistant (CNA). The incident involved a resident who provided $740 to a CNA after the CNA expressed financial difficulties related to car and bill troubles. The resident and the CNA had an agreement that the money would be repaid by a certain date. This transaction was reported by the resident to the activities staff, and the CNA later returned the money to the resident in the presence of the Director of Staff Development and the Concierge. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention clearly states that residents have the right to be free from such actions. Additionally, the facility's policy on gifts, gratuities, and payments prohibits employees from engaging in activities that conflict with the interests of the facility or its residents. Despite these policies, the incident occurred, indicating a failure to adhere to the established guidelines designed to protect residents from financial exploitation.
Failure to Implement Comprehensive Care Plan and Follow Physician Orders
Penalty
Summary
The facility failed to implement a comprehensive care plan and follow physician orders for a resident diagnosed with depression, who required antidepressant medication. The care plan included an intervention to administer the antidepressant medication, Trazadone, as ordered by the physician. However, during a review of the resident's medication administration record (MAR), it was found that there were missing entries for monitoring the resident for episodes of depression and adverse side effects of Trazadone on two separate occasions. Additionally, the resident did not receive the prescribed two doses of Trazadone on one occasion, receiving only one dose instead. The Director of Nursing and Medical Records Director acknowledged the missing entries and the failure to administer the medication as ordered, but could not provide additional documentation to indicate that the physician's orders were carried out on the specified dates. The facility's policy on comprehensive, person-centered care plans emphasizes the development and implementation of a care plan for each resident to maintain their highest practicable physical, mental, and psychosocial well-being. The failure to adhere to this policy and the physician's orders had the potential to negatively impact the resident.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide requested medical records in a timely manner to a resident's representative, violating the resident's rights. The representative of the resident made a verbal and written request for the resident's medical records on October 3, 2024. However, the facility did not fulfill this request because the representative had not signed the facility's specific authorization form titled 'Authorization Form For The Release of Health Information.' As of November 4, 2024, the requested medical records had not been provided to the resident's representative. Interviews with the Social Services Director, Director of Nursing, and Medical Records Director revealed that the facility's policy required the signing of their specific authorization form before releasing medical records, even if a verbal or written request had been made. This practice was contrary to the facility's policy and procedure titled 'Resident Rights,' which stated that residents have the right to access personal information and medical records. Additionally, the facility's 'Release of Information' policy indicated that residents could access their records within 48 hours of a written or oral request, excluding weekends and holidays. The facility's failure to adhere to these policies resulted in the deficiency.
Failure to Implement Care Plan for Monitoring Intake and Output
Penalty
Summary
The facility failed to adhere to a care plan intervention for a resident who had a urinary tract infection. The care plan, which was undated, required staff to monitor the resident's intake and output. However, during a review of the resident's care plan, the Director of Nursing and the Medical Records Director were unable to provide documentation that this intervention was carried out by the staff. The facility's policy on comprehensive, person-centered care plans, dated 2001, mandates that such plans include measurable objectives and timetables to meet the resident's needs. Despite this policy, the lack of documentation indicates that the care plan intervention was not implemented as required, potentially leading to negative outcomes for the resident.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to adhere to physician orders for catheter care for one resident, which had the potential to lead to negative outcomes such as an increased risk of urinary tract infections. During a review of the Treatment Administration Record (TAR) for the resident, it was found that there were missing or blank entries on multiple dates between May and August. The physician orders required monitoring of urine character and ensuring proper placement of the catheter to prevent obstruction of urine flow every shift. However, the TAR showed that these orders were not consistently documented, as confirmed by the Director of Nursing and the Medical Records Director during the review.
Failure to Administer Metoprolol as Ordered
Penalty
Summary
The facility failed to administer Metoprolol, a medication used to treat high blood pressure, according to physician orders for one of the sampled residents. The deficiency was identified during a record review and interview with the Director of Nursing and Medical Records Director. The resident's Medication Administration Record (MAR) indicated a physician order for Metoprolol to be given twice daily, with specific parameters for withholding the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60 beats per minute. On a specific date, the resident did not receive the scheduled dose of Metoprolol because the vital signs were incorrectly assessed as being outside the parameters, despite the recorded blood pressure and heart rate being within the acceptable range. The resident's care plan required adherence to the parameters for holding medication as ordered, which was not followed in this instance. The facility's policy and procedure for documentation of medication administration required documentation of reasons for withholding medication, which was not appropriately adhered to. The Director of Nursing and Medical Records Director acknowledged that the resident should have received the scheduled dose of Metoprolol based on the documented vital signs, indicating a failure in following the physician's orders and the facility's procedures.
Failure to Document Fall Prevention Intervention
Penalty
Summary
The facility failed to document the implementation of a care plan intervention for a resident who was at risk for falls. The resident, who had a history of falls and was diagnosed with an acute fracture of the right 8th and 9th ribs, head injury, and scalp laceration, was found sitting on a landing mat after falling while attempting to use the commode. The resident reported pain in the head and rib area and had a history of falling with a displaced fracture of the left clavicle, incontinence, lack of coordination, muscle weakness, and an unsteady gait. The care plan for the resident included an intervention to check the resident at least every two hours and as needed to assist with toileting. However, during a review of the resident's medical record, the Director of Nursing and Medical Records Director could not provide documentation that this intervention was carried out after the resident returned from the hospital. The facility's policies on comprehensive person-centered care plans and fall risk management emphasize the need for measurable objectives and monitoring of interventions, but the lack of documentation indicates a failure to adhere to these policies.
Failure to Monitor and Evaluate Resident's Skin Condition
Penalty
Summary
The facility failed to ensure timely monitoring and skin evaluation for a resident who was admitted following right knee surgery. The resident had a cast from the thigh to the foot, which was later replaced with a knee immobilizer. Despite physician orders to check for circulation, skin integrity, and signs of infection, the facility did not document any skin assessments until a deep tissue injury was discovered on the resident's right heel two days after the cast removal. The treatment nurse confirmed that there was no follow-up communication from the orthopedic doctor's office, and no additional orders were checked or documented. The wound consultant assessed the resident's right heel and found an unstageable injury, which was later debrided and classified as a stage IV wound. The consultant noted that such injuries could develop within a few hours due to pressure on a bony structure like the heel, especially given the resident's high-risk factors and limited mobility. The facility's policy indicated that any notable changes in the resident's condition should be documented, but this was not followed, leading to a delay in identifying and treating the pressure ulcer.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after a fall incident. The resident, who was admitted with diagnoses including Dementia, Anxiety, and Unsteadiness on Feet, had a history of fluctuating capacity to understand and make decisions and was assessed as having a high risk of falling. Despite an unwitnessed fall on 3/8/24 and a subsequent hip fracture discovered on 3/16/24, the care plan interventions remained unchanged from before the fall incident. This was confirmed during a review of the fall care plans dated 3/1/24 and 3/9/24, which showed similar interventions. The Nurse Supervisor acknowledged that the interventions should have been revised after the fall incident. Further interviews revealed that additional interventions were only added on 4/4/24, well after the fall incident. The Minimum Data Set (MDS) coordinator confirmed that an IDT meeting was held on 3/9/24 to address the fall, but the care plan was not updated to include new interventions. The facility's policy and procedure on care plans indicated that interventions should be derived from comprehensive assessments and input from the resident and their family, which was not adhered to in this case.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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